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Dr. James Goodwin: Scrutinizing a Health Care Revolution

Recovery Act grantee investigates how new hospital-based specialists, “hospitalists,” affect Medicare patients

By Susan Johnson

May 26, 2011

Recovery Act Investment: “Care of the Elder Hospitalized Patient: The Role of Hospitalists”; James Simeon Goodwin; University of Texas Medical Branch at Galveston; 2009: $345,823 (1R01AG033134-01A1); 2010: $310,665 (5R01AG033134-02). Funded by the National Institute on Aging.

Publications listing this Recovery Act Investment as providing grant support: Kuo Y-F and Goodwin JS. Effect of hospitalists on length of stay in the Medicare population: Variation according to hospital and patient characteristics. Journal of the American Geriatrics Society, 2010;58(9):1649–1657.

Sharma G, et al. Comanagement of hospitalized surgical patients by medicine physicians in the United States. Archives of Internal Medicine, 2010; 170(4):363–368.

Howrey BT, et al. Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke. Medical Care, epub ahead of print, 14 April 2011.

The Problem:
In the 1990s, a new medical specialist appeared: the hospitalist. Hospitalists, who are usually general internal medicine physicians, care only for hospitalized patients. Dr. James Goodwin says that economic forces driving an increase in medical cost-cutting measures, combined with physicians’ preferences for the defined work hours of hospital shifts, led to hospitalists’ sudden appearance and a subsequent rapid increase in the number of hospitalists in the U.S.

However, there was neither a detailed picture of where and how hospitalists were working nor information on how this new trend was affecting health care costs and patient health.

“There’s been a dramatic change in how hospital care is given. It happened really rapidly, it wasn’t really planned, and it hasn’t been examined. What are the benefits? What are the risks? Until we examine the changes, we won’t know.” —Goodwin

A wide-lens view of the entire U.S. hospital care system—with its approximately 40 million hospitalizations per year—was needed to get a better understanding of the effect of this new type of doctor.

Help From the American Recovery and Reinvestment Act (ARRA):
In the decentralized U.S. health care system, Medicare is the best available source of data on health and medical care across the country. This federal government program provides health insurance to 45 million Americans, including nearly all of those over age 65, regardless of income, location, or other factors. Medicare data therefore offer researchers a comprehensive view of the health care of the entire older population through time. (Researchers do not have access to any information that could identify individual patients.)

Goodwin applied for support from the National Institute on Aging (NIA) at NIH to purchase access to this data goldmine and to hire an analyst to dig into it. However, even though his application had a high score in review, it was barely edged out in the tight competition for funding—twice. Goodwin would have been forced to abandon this project idea if NIA had not received ARRA funds at just the right time to extend its support to projects like his.

“I think there’s going to be a reconsideration of the role of hospitalists.” —Goodwin

James S. Goodwin, M.D., George and Cynthia Mitchell Distinguished Chair of Geriatric Medicine and director of the Sealy Center on Aging at the University of Texas Medical Branch

James S. Goodwin, M.D., George and Cynthia Mitchell Distinguished Chair of Geriatric Medicine and director of the Sealy Center on Aging at the University of Texas Medical Branch

Answers Emerge:
The data that Goodwin accessed with his timely ARRA grant showed his team that hospitalists are changing hospital care for Medicare patients. However, these changes might not be for the better.

On average, patients under the care of hospitalists have slightly shorter hospital stays than do similar patients without a hospital-based generalist physician, Goodwin’s team reported in the Journal of the American Geriatrics Society. This is especially true for the oldest patients with the most complicated health situations. But these patients are not necessarily going home sooner. A more detailed examination of stroke patients that Goodwin’s team published in the journal Medical Care showed that patients under the care of hospitalists were more likely to be discharged into an inpatient rehabilitation facility than similar patients were—and were more likely to be readmitted to the hospital within a month.

“There are two forces: hospitalists seem to be efficient, but the use of hospitalists disrupts the doctor–patient relationship. There’s a disruption of communication. When the patient goes home, the doctor who takes over their care may not know what happened in the hospital.” —Goodwin

But hospitalists may be playing a beneficial role as well, Goodwin’s research revealed. Since 2000, the number of Medicare surgery patients being “comanaged” by their surgeon and a hospitalist has spiked, Goodwin’s team reported in Archives of Internal Medicine. This trend is strongest among the oldest patients with several medical conditions. Previous studies have shown that comanagement improves efficiency and reduces patients’ adverse outcomes.

Looking to the Future
The Medicare dataset provided Goodwin and his team with a chance to describe the hospitalist phenomenon. Now, he and his team are beginning to detail how hospitalists affect care, whether for better or for worse.

“There’s an argument to be made for comanagement of surgical patients by hospitalists, because medical problems just sort of pop up. So having a [generalist] doctor to follow along with this makes sense. The surgeon takes care of the surgical stuff and the [hospitalist] takes care of the diabetes and other problems.” —Goodwin

But there is still much more about the hospitalist story that needs to be fleshed out, and Goodwin and his team are trying to do so before their ARRA support runs out in August 2011. Soon, they will release results that describe how hospitalists affect health care costs. The team is also examining whether there is a direct link between a hospitalist’s discharging a patient earlier and that patient’s returning to the hospital sooner.

As Goodwin emphasizes, defining a problem is the first step toward solving it. Thanks to the opportunity that ARRA provided to analyze the health care system, Goodwin and his team are laying the groundwork for improved care for hospitalized Americans.

“If there are some bad effects of the trend towards hospitalist care, we can change them — but only if they are defined.” —Goodwin

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